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	<title>体检预约服务平台 - 医通在线</title>
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<!--header st-->
<{include file="../templates/$newtpl/header.html"}>
<FORM style="margin-top:5px" action="/index.php?action=editappend_family_save"  method="post" enctype="application/x-www-form-urlencoded" name="appendform" target="_self" id="appendform">

<div class="row mb10 center_layout fix">
	<{include file="../templates/$newtpl/left.html"}>
	<div class="grid0 grid770">
		<div class="main_con">
			<div class="subline"><h4>家属预约登记</h4><a href="<{$__URL__}>help" target="_blank" class="yuyue"><s></s>预约须知</a></div>
			<div class="step"><img src="templates/images/step_1.png" /></div>
			<div class="con info_box">
				<dl class="form">
					<!--<dd>
					  <label class="label">公司：</label>
					  <{$enterprise_info.enterprise_name}></dd>-->
					<dd><label class="label">预约人：</label>
					<input name="name" type="text" class="input" id="name" value="<{$appendinfo.append_name}>" /><span style="color:red;font-size=12px;">(必填)</span>
					<!--<{$appendinfo.append_name}>&nbsp;--></dd>
					<dd><label class="label">有效证件：</label>
					<input name="type" type="radio" value="1" <{if $appendinfo.append_type ==1}>checked<{/if}>>
					  身份证
					  <input type="radio" name="type" value="2" <{if $appendinfo.append_type ==2}>checked<{/if}>>
					  护照
					  <input type="radio" name="type" value="3" <{if $appendinfo.append_type ==3}>checked<{/if}>>
					  军官证
					  <input type="radio" name="type" value="4" <{if $appendinfo.append_type ==4}>checked<{/if}>>
					  其他

					<!--<{if $appendinfo.append_type ==1}>身份证<{/if}>
					<{if $appendinfo.append_type ==2}>护照<{/if}>
					<{if $appendinfo.append_type ==3}>军官证<{/if}>
					<{if $appendinfo.append_type ==4}>其他<{/if}>
					 ： <{$appendinfo.append_code}>--></dd>
					<dd>
                                            <label class="label">证件号：</label>
                                            <input name="code" type="text" class="input" id="code"  value="<{$appendinfo.append_code}>" /><span style="color:red;font-size=12px;">(必填)</span>
					</dd>
					<dd><label class="label">性别：</label>
                                        <{if $appendinfo.append_sex ==1}>男<{/if}>
                                        <{if $appendinfo.append_sex ==2}>女<{/if}>
					<input name="sex" type="hidden" value="<{if $appendinfo.append_sex ==1}>1<{else}>2<{/if}>" />

					  </dd>
					<dd><label class="label">出生日期：</label>
                                            <input name="birthday" type="text" class="input" id="birthday" value="<{$appendinfo.append_birthday}>" onFocus="WdatePicker({lang:'zh-cn',startDate:'1980-01-01'})"/><span class="">体检机构需要登记您的年龄，格式YYYY-MM-DD</span>
					<!--<{if $soinfo.source ==1}>
					<input name="birthday" type="text" class="input" id="birthday" value="<{$appendinfo.append_birthday}>" onFocus="WdatePicker({lang:'zh-cn',startDate:'1980-01-01'})"/><span class="fault">格式：YY-MM-DD</span>
					<{else}>
					<{$appendinfo.append_birthday}>
					<input name="birthday" type="hidden" class="input" id="birthday" value="<{$appendinfo.append_birthday}>"/>
					<{/if}>-->
					</dd>
					<dd>
                                            <label class="label"><em class="red"></em> 婚姻状况：</label>
                                            <{if $appendinfo.append_marry ==1}>未婚<{/if}>
                                            <{if $appendinfo.append_marry ==2}>已婚<{/if}>
                                            <input name="wedding" type="hidden" class="radiobtnfix"  value="<{if $appendinfo.append_marry ==1}>1<{else}>2<{/if}>" />
                                            <!--<span style="color:red;font-size=12px;margin-left: 10px;"><br />&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;已婚女性套餐比未婚套餐增加 阴超、白带常规、宫颈刮片，未婚女性做已婚套餐需在体检中心前台签字确认。</span>-->
                                            <!--<label class="mr20">
                                                <input name="wedding" type="radio" class="radiobtnfix"  value="1" <{if $appendinfo.append_marry ==1}>checked="checked"<{/if}>>未婚
                                            </label>
                                            <label>
                                                <input name="wedding" type="radio" class="radiobtnfix" value="2"  <{if $appendinfo.append_marry ==2}>checked="checked"<{/if}>>已婚
                                            </label>-->
                                        </dd>
					<dd><label class="label"><em class="red">*</em> 手机：</label><input name="tel" type="text" class="input" id="tel" value="<{$appendinfo.append_tel}>" /><span class="fault">(必填)&nbsp;&nbsp;确保您能收到预约短信提醒，请准确填写手机号！</span></dd>
										<dd><label class="label">邮箱：</label><input name="email" type="text" class="input" id="email" value="<{$appendinfo.append_email}>" /></dd>
				</dl>
				<p>重要提示：此次体检为实名制体检，请您正确填写家属个人资料，一旦预约成功，家属信息将不能在线修改，如需修改请致电400-820-6772-1-3。
				  <input name="appendid" type="hidden" id="appendid" value="<{$appendinfo.append_id}>">
</p>
				<div class="btn"><a href="###" onClick="jumpto_family_3();" title="下一步" class="btn_next"></a></div>
		  </div>
		</div>
	</div>
</div>
</FORM>
<{include file="../templates/$newtpl/foot.html"}>

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